<%= form_for(resource, :as => resource_name, :url => registration_path(resource_name)) do |f| %>
  <div id="login">
    <div id="cap-top"></div>
    <div id="cap-body">
      <div id="branding">
        <%= image_tag "pophealth_welcome.png", :id => 'imgLogo', :alt => 'popHealth logo' %>
      </div>
      <div class="panel">
        <div class="accountError">
          <%= devise_error_messages! %>
          <%= alert %>
        </div>
        <ul class="register">
          <li>
            <label for="first_name">Your First Name:</label>
            <%= f.text_field :first_name %>
          </li>
          <li>
            <label for="last_name">Your Last Name:</label>
            <%= f.text_field :last_name %>
          </li>
          <li>
            <label for="username">popHealth User Name:</label>
            <%= f.text_field :username %>
            <p>Must be at least 5 characters long.</p>
          </li>
          <li>
            <label for="email">Your Email Address:</label>
            <%= f.text_field :email %>
          </li>
          <li>
            <label for="password">popHealth Password:</label>
            <%= f.password_field :password %>
            <p>Must be at least 5 characters long.</p>
          </li>
          <li>
            <label for="password_confirmation">Confirm Password:</label>
            <%= password_field_tag :password_confirmation %>
          </li>
          <li>
            <label for="company">Your Organization:</label>
            <%= f.text_field :company %>
          </li>
          <li>
            <label for="company_url">Your Organization URL:</label>
            <%= f.text_field :company_url %>
          </li>
          <li>
            <label for="registry_name">Registry Name:</label>
            <%= f.text_field :registry_name %>
          </li>
          <li>
            <label for="registry_id">Registry Identifier:</label>
            <%= f.text_field :registry_id %>
          </li>
          <li>
            <label for="npi">National Provider Id:</label>
            <%= f.text_field :npi %>
          </li>
          <li>
            <label for="tin">Tax Identifier:</label>
            <%= f.text_field :tin %>
          </li>
        </ul>
        <% @bundles.each do |bundle| %>
        <%= raw bundle["license"] %>
        <% end %>
        <div id="regcheckbox">
          <%= f.check_box :agree_license %>
          <label for="agree_license">I agree to the above Terms and Conditions of use</label>
        </div>
        <div class="actions">
            <a class="whitebutton" href="/"><span>Cancel</span></a>
            <a class="bluebutton" href="#" onclick="submitRegisterform();"><span>Create</span></a>
        </div>
      </div><!-- end div.panel -->
      </div><!-- end #cap-body -->
    <div id="cap-bottom"></div>
  </div><!-- END #login -->
<% end %>
